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Ebola Situation Report - 19 August 2015

Total confirmed cases (by week, 2015)

SUMMARY

There were 3 confirmed cases of Ebola virus disease (EVD) reported in the week to 16 August, all of which were reported from Guinea. For the first time since the beginning of the outbreak in Sierra Leone, a full epidemiological week has passed with no confirmed cases reported from the country. Overall case incidence has held at 3 confirmed cases per week for 3 consecutive weeks. In addition, the number of contacts under observation has halved from over 1600 on 9 August to approximately 800 throughout 3 Guinean prefectures and 3 districts in Sierra Leone on 16 August. Almost 600 contacts in Tonkolili, Sierra Leone, completed the 21-day follow-up period on 14 August, accounting for most of the decline in the number of contacts under follow-up. However, there is still a significant risk of further transmission. In addition to the large number of contacts who remain under observation in Guinea and Sierra Leone, 45 contacts have been lost to follow-up in the Guinean capital Conakry over the past 6 weeks. Several high-risk contacts have also been lost to follow-up in the Sierra Leonean capital, Freetown. Rapid-response teams remain alert and ready to respond to further cases.

All of the 3 confirmed cases reported from Guinea in the week to 16 August are registered contacts, and are now receiving treatment in Ebola treatment centres. Two cases were reported from the Matam area of the capital, Conakry. Both cases were relatives and registered contacts of the single case reported from the Ratoma area of the city in the previous week (week ending 9 August). The remaining case was reported from the sub-prefecture of Moussayah in Forecariah. The case is a relative and registered contact of the case reported from the same sub-prefecture during the previous week. The origin of the previous week’s case remains under investigation. 796 contacts remain under follow-up in 3 western prefectures in Guinea (Conakry, Coyah, and Forecariah), compared with 927 contacts in 4 prefectures the previous week. All contacts previously under observation in the prefecture of Kindia have now completed the 21-day follow-up period.

No new cases were reported from Liberia in the week to 16 August. All contacts in Liberia have now completed their 21-day follow-up period. The last 2 patients with EVD in Liberia were discharged after completing treatment and testing negative for EVD for a second time on 23 July.

No cases were reported from Sierra Leone in the week to 16 August: the first week without a reported case since the onset of the outbreak in the country. A total of 72 contacts remain under follow-up across 3 districts (Tonkolili, Western Area Urban, and Western Area Rural), all of whom are associated with the Western Area Urban (Freetown) chain of transmission. All contacts associated with the recent cluster of cases in Tonkolili will complete the 21-day follow-up period on 23 August.

For the third consecutive week no health worker infections were reported from any of the affected countries. There have been a total of 880 confirmed health worker infections reported from Guinea, Liberia, and Sierra Leone since the start of the outbreak, with 512 reported deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION

There have been a total of 27 952 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia, and Sierra Leone (figure 1, table 1) up to 16 August, with 11 284 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). Three new confirmed cases were reported in Guinea in the week to 16 August.

The total number of confirmed cases is similar in males and females (table 2). Compared with children (people aged 14 years and under), adults aged 15 to 44 are approximately four times more likely to be affected in Guinea and Liberia, and three times more likely to be affected in Sierra Leone.

No new health worker infections were reported in the week to 16 August. Since the start of the outbreak a total of 880 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 512 reported deaths (table 5).

Data are based on official information reported by ministries of health. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Not reported due to the high proportion of probable and suspected cases that are reclassified. ‡Data not available.**Cases reported before 9 May 2015 are shaded blue. Due to ongoing surveillance and retrospective validation of cases and deaths, these totals may be subject to revision.

Table 2: Cumulative number of confirmed cases by sex and age group in Guinea, Liberia, and Sierra Leone

Country

Cumulative cases

By sex*
(per 100 000 population)

By age group‡
(per 100 000 population)

Male

Female

0-14 years

15-44 years

45+ years

Guinea

1591
(29)

1736
(32)

529
(11)

1897
(41)

857
(55)

Liberia§

1911
(96)

1838
(93)

561
(33)

2060
(121)

703
(132)

Sierra Leone

4792
(168)

5081
(175)

1978
(82)

5592
(216)

2129
(288)

Population figures are based on estimates from the United Nations Department of Economic and Social Affairs. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Excludes cases for which data on sex are not available. ‡Excludes cases for which data on age are not available. §Data are until 9 May.

Figure 2: Geographical distribution of confirmed cases reported in the week to 9 August 2015

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

Table 3: Cases and contacts by district/prefecture/county over the past 3 weeks

Data are based on official information reported by ministries of health. These numbers are subject to change due to ongoing reclassification, retrospective investigation and availability of laboratory results. *Data as of 9 August for Guinea and Sierra Leone and 6 August for Liberia. ¶One confirmed case in Tonkolili was retrospectively reported, with date of report 2 August 2015. ‡Includes Freetown.

Table 4: Location and epidemiological status of confirmed cases reported in the 3 weeks to 16 August 2015

Sub-prefectures/chiefdoms/districts that reported one or more confirmed cases in the 7 days to 16 August are highlighted. *Epi-link refers to cases who were not registered as contacts of a previous case (possibly because they refused to cooperate or were untraceable), but who, after further epidemiological investigation, were found to have had contact with a previous case, OR refers to cases who are resident or are from a community with active transmission in the past 21 days. ‡Includes cases under epidemiological investigation. §A case that is identified as a community death can also be registered as a contact, or subsequently be found to have had contact with a known case (epi-link), or have no known link to a previous case. ¶One confirmed case in Tonkolili was retrospectively reported, with date of report 2 August 2015. **Includes Freetown.¶One confirmed case in Tonkolili was retrospectively reported, with date of report 2 August 2015.

Figure 3: Geographical distribution of new and total confirmed cases in Guinea, Liberia and Sierra Leone

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

Data are confirmed cases and deaths only, apart from deaths in Sierra Leone, which include confirmed, probable, and suspected deaths. *Data are until 9 May. ‡Data as of 17 February.

GUINEA

Key performance indicators for the EVD response in Guinea are shown in table 6.

Three confirmed cases were reported from 2 prefectures—Conakry and Forecariah—in the week to 16 August (table 3, table 4, figure 2, figure 3).

Both cases in Conakry were reported from the Matam area of the city, and were relatives and registered contacts of the single case reported from the Ratoma area of the city in the previous week. 216 contacts remain under follow-up in the prefecture. A total of 45 contacts have been lost to follow-up in Conakry during the past 6 weeks.

The case reported from the sub-prefecture of Moussayah in Forecariah is the second to be reported from the sub-prefecture in the past 2 weeks. The case is the older brother and a registered contact of the 26-year-old woman who was identified as EVD-positive after post-mortem testing during the previous week, and is now receiving treatment at an Ebola treatment centre. Investigations are ongoing to determine the origin of infection of last-week’s case. 579 contacts remain under follow-up in the prefecture.

An interim analysis of the Ebola ça suffit! ring vaccination trial in Guinea suggests that the investigational rVSV-ZEBOV Ebola vaccine protects people exposed to EVD. The trial will continue in Guinea, with all rings around confirmed cases now receiving immediate vaccination. Previously, rings were randomly allocated to receive either immediate vaccination or vaccination 21 days after the confirmation of a case.

796 contacts remain under follow-up in 3 western prefectures in Guinea (Conakry, Coyah, and Forecariah), compared with 927 in 4 prefectures the previous week. Over 72% of all contacts are located in Forecariah, with 28% located in Conakry. A single contact is under follow-up in the prefecture of Coyah. All contacts previously being monitored in the prefecture of Kindia have now completed follow-up.

There were 3 (0.5%) unsafe burials reported in Guinea out of 577 recorded community deaths in the week to 16 August, compared with 6 (1%) unsafe burials out of 577 recorded community deaths in the previous week.

Including both initial and repeat testing, a total of 842 laboratory samples were tested in the week to 16 August. Most tests (88% in the week to 16 August) are of post-mortem swabs taken to rule out EVD as the cause of death.

Locations of the 8 operational Ebola treatment centres (ETCs) are shown in figure 7. No health-worker infections were reported from Guinea in the week to 16 August.

Locations of the 11 operational laboratories in Guinea are shown in figure 8.

Table 6: Key performance indicators for Guinea

For definitions of key performance indicators see Annex 2. Data are given for 7-day periods. *Includes repeat samples. ‡Data missing for 0–3% of cases. #Outcome data missing for 0–1% of hospitalized confirmed cases.

SIERRA LEONE

Key performance indicators for the EVD response in Sierra Leone are shown in table 7.

No cases were reported from Sierra Leone in the week to 16 August: the first week without a reported case since the onset of the outbreak in the country.

A total of 72 contacts remain under follow-up across 3 districts (Tonkolili, Western Area Urban, and Western Area Rural), all of whom are associated with the Western Area Urban (Freetown) chain of transmission. Several high-risk contacts have been lost to follow-up in Western Area Urban. All contacts associated with the recent cluster of cases in Tonkolili will complete their 21-day follow-up period on 23 August. Contacts in Freetown will remain under follow-up until 29 August.

Locations of the 10 operational Ebola treatment centres (ETCs) in Sierra Leone are shown in figure 7. No health worker infections were reported in the week to 16 August.

Laboratory indicators continue to reflect a heightened degree of vigilance, with 1775 new samples tested in the 7 days to 16 August. No new samples tested positive for EVD. Most tests (80% in the week to 16 August) are of post-mortem swabs taken to rule out EVD as the cause of death.

Locations of the 9 operational laboratories in Sierra Leone are shown in figure 8.

Table 7: Key performance indicators for Sierra Leone

For definitions of key performance indicators see Annex 2. Data are for 7-day periods.One confirmed case in Tonkolili was retrospectively reported, with date of report 2 August 2015. §Laboratory data missing for 14 July. ‡Data missing for 4–12% of cases. #Outcome data missing for 25–75% of hospitalized confirmed cases. An outcome is known for only 6 hospitalized, confirmed cases in each April and May.

Figure 6: Days since last confirmed case by district in Guinea, Liberia, and Sierra Leone

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

OTHER AFFECTED AND PREVIOUSLY AFFECTED COUNTRIES

Liberia was declared free of Ebola transmission on 9 May 2015, after reporting no new cases for 42 consecutive days. The country subsequently entered a 3-month period of heightened surveillance, during which approximately 80 blood samples and oral swabs are collected each day from potential cases and tested for EVD. On 29 June, this heightened surveillance detected an EVD-positive community death in Margibi County, Liberia—the first new confirmed case reported from the country since 20 March. The case was a 17-year-old male who first became ill on 21 June, died on 28 June, and subsequently tested positive for EVD. As at 12 July, 5 contacts associated with the first-detected case have since been confirmed as EVD-positive. Of the 6 confirmed cases reported since 29 June, 2 have died, and the remaining 4 have now all been discharged after treatment. The last case was discharged after testing negative for EVD for a second time on 23 July. All contacts have now completed follow-up.

Seven countries (Italy, Mali, Nigeria, Senegal, Spain, the United Kingdom and the United States of America) have previously reported a case or cases imported from a country with widespread and intense transmission.

ETCs scheduled for closure will be decommissioned only when and where the epidemiological situation and the strength of referral pathways through non-EVD facilities allow. Several ETCs will be unstaffed but remain on a stand-by level of readiness, whereby stocks of protective equipment and essential medicines will be kept on-site such that the facility can become operational within 48 hours. This transition would be triggered by higher occupancy rates in nearby ETCs. Strategically located core ETCs will remain fully operational at their current capacity (Maintain). The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

PREPAREDNESS OF COUNTRIES TO RAPIDLY DETECT AND RESPOND TO AN EBOLA EXPOSURE

The introduction of an EVD case into unaffected countries remains a risk as long as cases exist in any country. With adequate preparation, however, such an introduction can be contained through a timely and effective response.

WHO’s preparedness activities aim to ensure all countries are ready to effectively and safely detect, investigate, and report potential EVD cases, and to mount an effective response. WHO provides this support through country support visits by preparedness-strengthening teams (PSTs) to help identify and prioritize gaps and needs, direct technical assistance, and provide technical guidance and tools.

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

Priority countries in Africa

The initial focus of support by WHO and partners is on highest priority countries – Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal—followed by high priority countries—Benin, Burkina Faso, Cameroon, Central African Republic, Democratic Republic of the Congo, Ethiopia, Gambia, Ghana, Mauritania, Niger, Nigeria, South Sudan, and Togo. The criteria used to prioritize countries include the geographical proximity to affected countries, the relative magnitude of trade and migration links, and the relative strength of their health systems.

Since 20 October 2014, PSTs have provided technical support in Benin, Burkina Faso, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, South Sudan, and Togo. Technical working group meetings, field visits, high-level table-top exercises, and field simulations have helped to identify key areas for improvement. Each country has a tailored plan to strengthen operational readiness.

From October 2014 to August 2015 WHO has undertaken over 264 field deployments to priority countries to assist with the implementation of national plans.

WHO provides personal protective equipment (PPE) modules containing minimum stocks to cover staff protection and other equipment needs to support 10 beds for 10 days for all staff with essential functions. PPE modules have been delivered or are in the process of being delivered to all countries on the African continent. In addition, all countries have received one PPE training module.

Contingency stockpiles of PPE are in place in the United Nations Humanitarian Response Depots (UNHRD) in Accra and Dubai, and are available to any country in the event that they experience a shortage.

Follow-up support to priority countries

Following the initial PST assessment missions to the 14 priority countries undertaken in 2014, a second phase of preparedness-strengthening activities have provided support on a country-by-country basis. Activities in the last week are highlighted below.

In Cameroon from 11 to 14 August, WHO led a PST follow-up visit to review the country’s level of readiness, with a focus on surveillance, points of entry, and logistics. During the visit, the ministry of health, WHO, and partners updated Cameroon’s national operational plan for preparedness.

In Gambia, WHO is supporting the ministry of health from 17 to 21 August to plan simulation exercises to evaluate the country’s response systems.

In Ghana, alongside the Department for Health Services, WHO, other partners, and ministries conducted a workshop to develop national guidelines on safe and dignified burials. The group discussed strategies for community engagement, including the importance of cultural and religious sensitivity. Community representatives, religious leaders, traditional healers, and local government officials will be consulted about their opinions on policies in an effort to actively improve community engagement.

In Guinea Bissau, preparedness support continues to be provided at the central level and in two priority regions (Tombali and Gabu) through WHO’s sub-offices. Activities implemented by WHO and partners during the reporting period with national authorities include: a mapping of local partner activities and coordination meetings in Tombali and Gabu (involving regional authorities and partner organisations); establishment of community event-based surveillance project with the U.S. Centre for Disease Control (CDC), International organisation for Migration, and WHO support; border post visits and assessments in Gabu region by the WHO Representative and sub-regional teams; and a simulation exercise to test capacity for case isolation, safe sample collection, and shipment.

EVD preparedness officers

Dedicated EVD preparedness officers have been deployed to support the implementation of country preparedness plans, coordinate partners, provide a focal point for inter-agency collaboration, provide specific technical support in their respective areas of expertise, and provide capacity development to national WHO staff. Preparedness officers are currently deployed to Benin, Cameroon, Central African Republic, Côte d’Ivoire, Ethiopia, Gambia, Ghana, Guinea-Bissau, Mali, Mauritania, Niger, Senegal, and Togo.

Training, exercises, and simulations

Priority countries that have achieved a minimum of 50% implementation of preparedness checklist activities are encouraged to undertake a series of drills on elements of an EVD response, and a functional exercise to test the coordination of the Ebola operations centre.

Trainings in Gambia (rapid response teams), Mauritania (points-of-entry), and Côte d’Ivoire (clinical management and IPC in Guiglo and Toulepleu) are currently being planned.

Surveillance and preparedness indicators

Indicators based on surveillance data, case-management capacity, laboratory testing, and equipment stocks continue to be collected on a weekly basis from the four countries that share a border with affected countries: Côte d’Ivoire, Guinea-Bissau, Mali, and Senegal.

An interactive preparedness dashboard based on the WHO EVD checklist is now available online.

ANNEX 1: COORDINATION OF THE EBOLA RESPONSE ALONG 4 LINES OF ACTION

WHO continues to work with many partners in response to the EVD outbreak, including the African Union, the Economic Community of West African States, the Mano River Union, national governments, non-governmental organizations, and UN agencies, and technical institutions and networks in the Global Outbreak Alert and Response Network (GOARN). Agencies responsible for coordinating 4 key lines of action in the response are given below.

Lines of action

Lead agency

Case management

WHO

Case finding, laboratory services and contact tracing

WHO

Safe and dignified burials

International Federation of Red Cross and Red Crescent Societies (IFRC)

Community engagement and social mobilization

UNICEF

ANNEX 2: DEFINITIONS OF PHASE 2 KEY PERFORMANCE INDICATORS

Indicator

Numerator

Numerator source

Denominator

Denominator source

Cases and deaths

Number of confirmed cases

# of confirmed cases

Guinea: Daily WHO situation reports

Sierra Leone: Daily Ministry of Health Ebola situation reports

N/A

N/A

Number of confirmed deaths

# of confirmed deaths

Guinea: Daily WHO situation reports

Sierra Leone: Daily Ministry of Health Ebola situation reports

N/A

N/A

Proportion of EVD- positive reported community deaths

# of community deaths for which a sample was taken

# of community deaths with positive EVD swab results

Guinea: Weekly WHO situation reports

Sierra Leone: Daily Ministry of Health situation reports

N/A

N/A

Diagnostic services

Number of samples tested and percentage with positive EVD results

# of new samples tested

# of new samples tested with a positive EVD result

Guinea: Laboratory database

Sierra Leone: Daily Ministry of Health Ebola situation reports

N/A

# of new samples tested

Guinea: Laboratory database

Sierra Leone: Daily Ministry of Health Ebola situation reports

Contact tracing

Percent of new confirmed cases from registered contacts

# of new confirmed cases registered as a contact

Guinea: Weekly WHO situation reports

Sierra Leone: Weekly Ministry of Health Surveillance Report

# of new confirmed cases

Guinea: Daily WHO situation reports

Sierra Leone: Daily Ministry of Health Ebola situation reports

Hospitalization

Time between symptom onset and case hospitalization (days)

Time between symptom onset and hospitalization of confirmed, probable or suspected case (geometric mean # of days)

Clinical investigation records

N/A

N/A

Outcome of treatment

Case fatality rate (among hospitalized cases)

# of deaths among hospitalized cases (confirmed)

Clinical investigation records

# of hospitalized cases (confirmed) with a definitive survival outcome recorded

Clinical investigation records

Infection Prevention and Control (IPC) and Safety

Number of newly infected health workers

# of newly infected health workers

Guinea / Sierra Leone: Daily WHO situation reports

N/A

N/A

Safe and dignified burials

Number of unsafe burials reported

# of reports/alerts of burials that were not known to be safe

Guinea: Weekly WHO situation reports

N/A

N/A

Social mobilization

Number of districts with at least one security incident or other form of refusal to cooperate

# of districts with at least one security incident or other form of refusal to cooperate in the past week